Prevalence and associations of depression, anxiety, and stress among people living with HIV: A hospital‐based analytical cross‐sectional study

Abstract Background and Aims An important but much less researched burden of human immunodeficiency virus (HIV) in Sub‐Saharan Africa includes the associated mental health outcomes of living with the virus. This study aimed to estimate the prevalence of depression, anxiety, and stress, and describe some of the socio‐demographic associations among people living with HIV (PLHIV) in Ghana. Methods A cross‐sectional study was conducted at the Cape Coast Teaching Hospital, Ghana. Simple random sampling was used to recruit 395 PLHIV who access HIV‐related services at the antiretroviral therapy clinic. The Depression, Anxiety, and Stress Scale‐21 was used to assess prevalence of depression, anxiety, and stress. Frequencies and percentages were used to estimate the prevalence and multivariable logistic regression was used to evaluate sociodemographic factors associated with depression, anxiety, and stress. Results The prevalence estimates of depression, anxiety, and stress among PLHIV were 28.6% (95% confidence interval [CI] 24.4–33.3), 40.8% (95% CI = 36.0–45.8), and 10.6% (95% CI = 7.9–14.1), respectively. Females reported higher prevalence of depression (32.2%; 95% CI = 27.2–37.7), anxiety (44.0%; 95% CI = 38.4–49.6), and stress (12.6%; 95% CI = 9.4–17.0) compared to depression (17.5%; 95% CI = 11.1–26.4), anxiety (30.9%; 95% CI = 22.5–40.7), and stress (4.1%; 95% CI = 1.2–10.4) among males. PLHIV without a regular partner were about 0.63 increased odds of experiencing anxiety compared to those with a regular partner (AOR = 0.63, 95% CI = 0.40–1.00: p = 0.049). PLHIV without formal education were about 0.49 and 0.44 increased odds to experience anxiety and stress, respectively compared to those with tertiary education. Conclusions Generally, the levels of stress, anxiety, and depression are high among PLHIV, but disproportionately higher among females. Mental health assessment and management should be integrated into the HIV care services. There should be capacity building for health care workers to offer differentiated service delivery based on mental health care needs of PLHIV.

prevalence rate of about 2%. 2 The chronicity of HIV/AIDS is not only impacting on physical health but is also having enormous challenges on psychological wellbeing. 3 In particular, HIV-related stigma, depression, anxiety, and stress have been reported among PLHIV. [4][5][6] Thus, a major burden of living with HIV relates to the negative mental health outcomes and the psychosocial impact of the disease, including stigma, depression, anxiety, self-esteem, loneliness, and reduced quality of life. 3,4 Studies suggest that PLHIV often suffer from depression and anxiety disorders as they adjust to the diagnosis, struggle with the meaning of a positive test result, adapt to life with chronic, life-threatening illness, and witness of the death of a family member or a friend with HIV/AIDS. 7,8 Evidence suggests higher estimates of mental disorders in PLHIV.
Recent studies from high-income countries, for example, the United States, suggest a 36% prevalence of depression and 16% anxiety disorders among a large national sample of HIV-positive men and women during the previous 12 months. 9 In sub-Sahara Africa, the prevalence of mental disorders among PLHIV during a period of 3 months was estimated to be as high as 19%. 10 For example, it is estimated that 32% and 34.4% of people living with HIV in South Ethiopia suffer from depression and anxiety, respectively. 4 Given the evidence of strong association of poor mental health outcomes with living with HIV, there is a need for both targeted and universal mental health screening and having mental health prevention and treatment options integrated into HIV care regimes. 1 Although mental health has been integrated into the care of HIV/AIDS mostly in high-income countries as a result of substantial evidence supporting the linkage between mental health and HIV, little is still known in sub-Sahara African countries, including Ghana. 8 Considering that Ghana  The sample size was predetermined by applying the Miller and Brewer's formula: at 95% confidence level, n = N N a (1 + ( ) ) 2 . Where: n= desired sample size, N = target population (3972), a = level of statistical significance (0.05), and 1 is a constant. 12 Therefore, n (the predetermined sample size) = 363. However, to make up for incomplete data, the sample size was increased by 10% bringing the predetermined sample size to 399. 13 A simple random sampling technique was used to recruit participants. The sample frame was determined by acquiring the list of all adults living with HIV/AIDS who received service from the ART clinic from the hospital's records department. Each name in the sample frame was numbered. A random number generator was used to generate random numbers and registered the name in the sample frame corresponding to the numbers to constitute the sample.
This was continued until the required number of participants (399) was met.

| MEASURES
Data were collected using a self-report anonymous questionnaire.
The questionnaire had three sections. The first section focused on socio-demographic characteristics of participants (e.g., age, gender, Five research assistants with at least a bachelor's degree were recruited to assist with data collection. They were trained on the type of information to be collected from participants and how to uphold the ethical position of the data collection process and the entire study protocol. The training lasted for 4 h and ensures that they understood the data collection instrument. The questionnaires were administered privately to each participant by the first author or a trained research assistant at a convenient place at the ART clinic (e.g., selected consulting rooms). Averagely, it took each participant approximately 20 min to complete the questionnaire. Participants who were not literate were assisted by the first author or research assistants to complete the questionnaire. Three hundred and ninetyfive questionnaires were returned with complete data, yielding a response rate of 99%.
Pre-testing of the instrument was conducted to establish the appropriateness of the instrument and determine how feasible they would translate into the local dialect in the full-scale study. The instrument was administered to 40 people and the feedback from pretesting was used to improve the use of the instrument.
This study was performed in accordance with the Helsinki Declaration and approved by the Ethics Review Committee of Cape Coast Teaching Hospital, Ghana (reference: CCTHERC/EC/2021/ 028). The purpose of the study, anonymity, voluntary participation, and confidentiality of the information were explained to participants to seek their written consent. Only those who gave written informed consent were included in the study. Participants could withdraw from the study at any point without any adverse effect. The hospital where the study was carried out gave permission for the study to be carried out.

| DATA ANALYSIS
STATA version 16 was used for the statistical analysis. Frequencies and percentages were used to estimate the prevalence, summary statistics was based on the distribution of the data. For normally distributed variables, mean and standard deviation was used. Bivariable analysis using t-test or χ 2 test (as appropriate) and multivariable logistic regression were used to evaluate sociodemographic factors and risky health behaviors associated with depression, anxiety, and stress. Age and gender were the only a priory variable. Sociodemographic variables were included in the final logistics model regardless of the statistical significance of their bivariable associations with the outcomes. However, variables with acute sparse data were excluded. 16 For ease of data interpretation, each of the outcomes (depression, anxiety, and stress) were dichotomized. The response categories "mild," "moderate," "severe," and "extremely severe" were merged and renamed "depressed," "anxious," and "stressed," while the remaining response category, "normal," was maintained to indicate "normal mood level," "normal anxiety level," and "normal stress level." Statistical significance was based on the p-value (p < 0.05) and associated 95% confidence interval (95% CI).   Table 1).
Currently without a regular partner Religion

| Stress
Similarly, across the total sample, only two factors showed

| GENDER DIFFERENCES IN FACTORS ASSOCIATED WITH DEPRESSION, ANXIETY, AND STRESS
The statistical analysis was stratified according to gender to assess the bivariable and multivariable associations of the three outcomes.
Interestingly, in both the bivariable and multivariable analyses, no association reached the desired threshold of statistical significance among females (Table 4)   The current study has also shown that females are more likely than males to report depression, anxiety, and stress. This evidence is consistent with findings from similar studies. 4,19,23 Generally, this finding is not surprising for the reason that females tend to experience and report more internalizing problems than males. 24 This study's findings further indicate that, a vast majority of PLHIV do not drink alcohol. It appears that, the estimates from this study are not consistent with findings of similar studies which indicate a high incidence of alcohol use among PLHIV. [28][29][30] Maladaptive means of coping may lead to an increase in the use of alcohol among PLHIV and may impact their health negatively. 29,30 The low consumption of alcohol among PLHIV in this current study, may be associated with the use an adaptive coping strategy. PLHIV require a great deal of social and emotional support to help them deal with the psychosocial burden of living with the virus. 25 However, within the socio-cultural setup of Ghana, sexually transmitted diseases are highly stigmatized and gender inequality is still pervasive; women continue to experience inequality, lower social status, and increased vulnerability to discrimination and various forms of abuse. 25 In these circumstances, women living with HIV are more likely (than men) to experience social adversities, social ostracism and isolation, and an inability to attract meaningful social support, thereby increasing their vulnerability to negative mental health outcomes such as loneliness, depression, and anxiety.
The study findings suggest also that PLHIV without a regular partner are more likely to report anxiety compared to those with a regular partner. A cross-sectional study in Zambia also found high prevalence of depression among unmarried, widowed, and divorced women. 19 People who are in less stressful marriages may be less vulnerable to mental health challenges. 26 Although marriage may not necessarily militate against the onset of mental illness in partners, meaningful spousal support may promote resilience and could present as a potential protective factor against mental health challenges among persons in marital relationships. 27 For PLHIV, having a supportive spouse is critical to promoting resilience in the face of mental health challenges. 28 The key finding that PLHIV without formal education (compared to those with tertiary education) are at increased odds of experien-